Stroke and Brain InjuryStroke and Brain Injury
A stroke or sometimes called a “brain attack” occurs when blood flow to a region of the brain is obstructed,thebrain cells, deprived of the oxygen and glucose needed to survive,die.
Modifiable Risk Factors
Hypertension (most important)Cigarette smokingDiabetesCardiac or arterial diseaseAtrial fibrillationMetabolic syndrome,Poor dietPhysical inactivityAlcoholism
Stroke is the third leading cause of death in America and the number one cause of adult disability.700,000people in the United States suffer a stroke, or ≈1 person every 45 seconds, and nearly one third of these strokes are recurrent.More than half of men and women under the age of 65 years who have a stroke die within 8 years.
23% of stroke victims have a previous stroke historyThe 30 day survival rate is 88% for ischemic and 62% for hemorrhagic strokesApproximately 25% of stroke victims die as a result of the event itself or complicationsOnly 26% of stroke victims recover most or all of their pre-stroke health an function
How does a stroke occur?
Ischemic strokeis similar to a heart attack, except it occurs in the blood vessels of the brain. Clots can form either in the brain's blood vessels, in blood vessels leading to the brain or even blood vessels elsewhere in the body which then travel to the brain.87%of all strokes are of this nature.Hemorrhagicstrokesoccur when a blood vessel in the brain breaks or ruptures. The result is blood seeping into the brain tissue, causing damage to brain cells. The most common causes of hemorrhagic stroke are high blood pressure and brain aneurysms. An aneurysm is a weakness or thinness in the blood vessel wall.
Weaknessor numbness of the face, arm or leg on one side of the bodyLossof visionLossof speech, difficulty talking or understanding what others are sayingSuddenorsevere headache with no known causeLossof balance, unstable walking, usually combined with another symptom
Signs of a stroke: FAST
What is FAST?Facialweakness - can the person smile? Has their mouth or eye drooped?Arm weakness - can the person raise both arms?Speech problems - can the person speak clearly and understand what you say?Time to call911
About30% of patients who subsequently have anischemicstroke have a small warning episode termed a transientischemicattack.ATIA is like anischemicstroke in that it is results in the sudden loss of function of a particular part of the body because of a sudden lack of blood flow to a part of the brain.Thedifference between a TIA and anischemicstroke is that in a TIA the symptoms disappear completely within 24 hours. In 75% of cases the symptoms clear within one hour, often within only a few minutes, because the blockage in the artery clears itself very quickly before the affected brain tissue has died. 30% of people have damage evident on sensitive brain imaging techniques such as MRI after a TIA.http://brainfoundation.org.au/a-z-of-disorders/107-stroke
Yourdoctor will check yourpulse and bloodpressure, and examine the rest of your body (heart, lungs,etc).Thedoctor will check your strength, sensation, coordination and reflexes. In addition, you will be asked questions to check your memory, speech and thinking.
Tests and Evaluations
CT scanA CT scan uses X-rays to produce a 3-dimensional image of your head. A CT scan can be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems of the brain and brain stem.MRI scanAnMRI uses magnetic fields to produce a 3-dimensional image of your head. The MR scan shows the brain and spinal cord in more detail than CT. MR can be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems involving the brain, brain stem, and spinal cord.http://www.strokecenter.org/patients/stroke-diagnosis/how-a-stroke-is-diagnosed/
Tests that View the Blood Vessels that Supply the Brain
CartoidDopplerPainless ultrasound waves are used to take a picture of the carotid arteries in your neck, and to show the blood flowing to your brain. This test can show if your carotid artery is narrowed by arteriosclerosis (cholesterol deposition).Transcranialdoppler(TCD)Ultrasound waves are used to measure blood flow in some of the arteries in your brain.MRAThis is a special type of MRIscanwhich can be used to see the blood vessels in your neck or brain.Cerebral ArteriogramAcatheter is inserted in an artery in your arm or leg, and a special dye is injected into the blood vessels leading to your brain. X-ray images show any abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms orarterio-venous malformations). Cerebral arteriogram is a more difficult test than carotiddoppleror MRA, but the results are the most accurate.
A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain suffers a lack of blood flow and which part was affected.Paralysisor loss of muscle movement.Sometimes a lack of blood flow to the brain can cause a person to become paralyzed on one side of the body, or lose control of certain muscles, such as those on one side of the face. With physical therapy, you may see improvement in muscle movement or paralysis.Difficulty talking or swallowing.A stroke may cause a person to have less control over the way the muscles in the mouth and throat move, making it difficult to talk, swallow or eat. A person may also have a hard time speaking because a stroke has caused aphasia, a condition in which a person has difficulty expressing thoughts through language.
Memory loss or trouble with understanding.It's common that people who've had a stroke experience some memory loss.Pain.Ifa stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. You may also be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve as more time passes. But because the pain is caused by a problem in the brain instead of a physical injury, there are few medications to treat CPS.Changes in behavior and self-care.People who have a stroke may become more withdrawn and less social or more impulsive.
Medical treatment for stroke:Specific treatment for stroke will be determined by your physician based on:yourage, overall health, and medical historyseverityof the strokelocationof the strokecauseof the strokeyourtolerance for specific medications, procedures, or therapiestypeof stroke
Medicationsused to the dissolve blood clot(s) that cause an ischemic strokeMedications that dissolve clots are calledthrombolyticsorfibrinolyticsand are commonly known as "clot busters.”Medicationsand therapy to reduce or control brain swellingCorticosteroids and special types of intravenous (IV) fluids are often used to help reduce or control brain swelling, especially after a hemorrhagicstroke.Medicationsthat help protect the brain from damage and ischemiaMedications of this type are calledneuroprotectiveagents, with some still under investigation in clinical trials.
Types of surgery to treat or prevent a stroke:
CarotidendarterectomyCarotidendarterectomyis a procedure used to remove plaque and clots from the carotid arteries, located in the neck. These arteries supply the brain with blood from the heart.Endarterectomymay help prevent a stroke from occurring.CarotidstentingA large metal coil (stent) is placed in the carotid artery much like a stent is placed in a coronary artery. The femoral artery is used as the site for passage of a special hollow tube to the area of blockage in the carotid artery. This procedure is often done in radiology labs, but may be performed in thecathlab.CraniotomyA craniotomy is a type of surgery in the brain itself to remove blood clots or repair bleeding in thebrain.surgeryto repair aneurysms andarteriovenousmalformations (AVMs)An aneurysm is a weakened, ballooned area on an artery wall that has a risk for rupturing and bleeding into the brain. An AVM is a congenital (present at birth) or acquired disorder that consists of a disorderly, tangled web of arteries and veins. An AVM also has a risk for rupturing and bleeding into the brain. Surgery may be helpful, in this case, to help prevent a stroke from occurring.
Effects of disease on ability to exercise
Following a stroke, submaximal oxygen uptake is increased and peak oxygen uptake is decreased.V02 peak is half that of age-matched healthy counterparts, resulting in a lower maximal workloads.Only 20-34% of individuals with a stroke are able to achieve 85% of age predicted maximal heart rate.
Effects of disease on ability to exercise
The functional implications for stroke survivors are that they tend to breath harder with exertion, fatigue approximately 2.5 times more rapidly, and are less efficient in mobility skills and activities of daily living.This leads individuals to adopt a sedentary lifestyle
Effects of medications on exercise
Vasodilators may increase the cool-down period required after exercise to prevent post exercise hypotension.Medications that limit cardiac output by reducing heart rate may cause lower peak heart rates.Diuretics reduce fluid volume and may alter electrolyte balance, causing dysrhythmias.
Effects (acute) of a session of exercise
Stroke patients have been shown to achieve significantly lower maximal workloads and heart rate and blood pressure responses than control subjects during progressive exercise testing to volitional fatigue.
Effects (chronic) of Training
Recurrent stroke and coronary artery disease (CAD) are leading cause of death following stroke; exercise alone can reduce mortality rate by 20% or moreLeg cycling results in 60% greater VO2peakTreadmill-workload response-blood pressure-Resting heart rate-Cholesterol levels
Effects (chronic) of exercise training
Exercisecan improve aerobic capacity, cardiovascular fitness, motor performance and mood after stroke.
Supervised by a physician with a 12-lead electrocardiogram (ECG)Leg cycle (5-10 W/min using ramp protocol)Treadmill (0.5-2 METS/stage)6-12 minute walkCombined Arm and Leg Ergometer (60% peak power)Steppers (25 steps/minute with increases at 7 steps)Muscle Strength TestsFlexibility TestsNeuromuscular Tests
Aerobic: Cycle and Treadmill testsMeasures: HR, BP, RPE, Vo2peakEndpoints: Seriousdysrthythiams, >2ST-segment depression or evaluation, ischemicthreshhold, SBP>250mmhgor DBP>115mmhg, Volitional fatigueStrength: Manual Muscle TestMeasures: Force generated on dynamometerEndpoints: Pounds, Kilograms, # of reps, Max torque
Three-tier exercise trainingaproach- First stage – Return to functionSecond stage – reduce risk of another stroke by influencing glucose regulation, decreasing weight & blood pressure, & regulating blood lipid levelsThird Stage – Improve aerobic fitness by exercising 20-60 , three – seven days/week
Aerobic- 40-70% V02peak, 3-5 days/week, 20-60 minsessionStrength – 3 sets of 8-12 reps, 2 days/weekFlexibility – 2 days/week (before and/or after aerobic & strength activities)Neuromuscular- 2 days/week (consider performing on same day as strength activities)
Summary and conclusion
A stroke or sometimes called a “brain attack” occurs when blood flow to a region of the brain isobstructedStroke is the third leading cause of death in America and the number one cause of adult disability.Ischemic stroke (blood clot) 87% Hemorrhagic (busted artery)13%What is FAST?
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